Adversity coping capability and its associations with mental health and family wellbeing amid the COVID-19 pandemic in Hong Kong.

BACKGROUND: Adversity coping capability (ACC) is important amid the COVID-19 pandemic. We examined the associations of ACC as measured by our one-item ACC scale (ACC-1) with mental health, family well-being and validity of ACC-1 in Hong Kong. METHODS: A cross-sectional survey was conducted on Hong Kong Chinese adults aged ≥ 18 years by landline, mobile phone, and online survey from February to March 2021, when the fourth wave of COVID-19 was under control. ACC-1 consisted of the question: "How do you rate your capability to cope with adversities?" with higher scores (0-10) indicating stronger ACC. The associations of ACC with socioeconomic characteristics, resilience, mental health, and family wellbeing were examined by linear regression coefficients (ßs). Data were weighted by sex, age, and education of the general population. RESULTS: Of 7441 respondents, after weighing, 52.2% were female and 79.1% were aged 18 to 64 years. ACC-1 showed good construct validity, with higher ACC being associated with higher levels of resilience (adjusted ß = 0.29), personal happiness (0.55), family happiness (0.42), family wellbeing (0.41), and family communication quality (0.41), and lower levels of depressive symptoms (-0.30), anxiety (-0.30), loneliness (-0.15); incremental validity with additional contributions of ACC to mental health and family wellbeing; and known-group validity with older age and favorable socioeconomic characteristics showing higher ACC (all P < 0.02). Females (mean ± standard deviation: 6.04 ± 1.82 vs 6.15 ± 1.96 [male]) and unemployed respondents (5.30 ± 1.99 vs 6.11 ± 2.03 [in paid employment]) had lower ACC (all P ≤ 0.02). CONCLUSIONS: We have first shown that stronger ACC was associated with better mental health and family wellbeing, and the results support ACC-1 as a simple and valid measure of ACC.

Gamified Strength Recognition and Quiz to Enhance COVID-19 Prevention, Knowledge, Behaviors, and Family Well-Being.

Background: Promoting COVID-19 prevention is key to pandemic control and innovative interventions can help communicate reliable science to the public. Under the Hong Kong Jockey Club SMART Family-Link Project, we developed and evaluated a pilot intervention for promoting COVID-19 prevention through a web-based family game, guided by the Theory of Planned Behavior and a strength-based approach. Methods: The "SMART Epidemic prevention" pilot theme was launched to the public on September 21, 2020 for 4 weeks. The game had two parts: (i) strength recognition and (ii) quiz questions on knowledge and behaviors about COVID-19 prevention. Simple baseline, in-game, and postgame evaluation assessed players' perceived knowledge, behaviors, family well-being, game satisfaction, and perceived benefits. Results: Of 86 registered families, 55 played actively, including 212 players (51% female, 35% aged below 18) who self-identified as children (44%), parents (39%), and grandparents (11%). In weeks 1 and 4, an average of 7 and 18 game rounds were played per family, and 86.6% and 75.9% of rounds had perfect (2) behavior matches. Postgame evaluation with 51 families showed improvements in epidemic prevention knowledge and behaviors, family communication, family happiness (all P < 0.001), and family relationship (P = 0.002) with small effect sizes (0.15-0.29). Overall game satisfaction was rated 4.49 (scale of 1-5). Ninety-four percent of families shared knowledge from the game with others. Conclusions: Our pilot web-based family game first showed preliminary evidence on enhancing COVID-19 prevention knowledge and behaviors, and family well-being, with participants recognizing family strengths, reporting high satisfaction and various perceived benefits, and showing sustained gameplay. Trial Registration: The research protocol was registered at the National Institutes of Health (Identifier No. NCT04550065) on September 16, 2020.

Factors associated with willingness and preferences to attend family services in Hong Kong: A population-based survey.

Objective: Family services are open to the community at large as well as vulnerable groups; however, little is known about the willingness of communities to attend such services. We investigated the willingness and preferences to attend family services and their associated factors (including sociodemographic characteristics, family wellbeing, and family communication quality) in Hong Kong. Methods: A population-based survey was conducted on residents aged over 18 years from February to March 2021. Data included sociodemographic characteristics (sex, age, education, housing type, monthly household income, and the number of cohabitants), willingness to attend family services to promote family relationships (yes/no), family service preferences (healthy living, emotion management, family communication promotion, stress management, parent-child activities, family relationship fostering, family life education, and social network building; each yes/no), family wellbeing, and family communication quality (both scores 0-10). Family wellbeing was assessed using the average scores of perceived family harmony, happiness and health (each score 0-10). Higher scores indicate better family wellbeing or family communication quality. Prevalence estimates were weighted by sex, age and educational level of the general population. Adjusted prevalence ratios (aPR) for the willingness and preferences to attend family services were calculated in relation to sociodemographic characteristics, family wellbeing, and family communication quality. Results: Overall, 22.1% (1,355/6,134) and 51.6% (996/1,930) of respondents were willing to attend family services to promote relationships or when facing problems, respectively. Older age (aPR = 1.37-2.30, P < 0.001-0.034) and having four or more cohabitants (aPR = 1.44-1.53, P = 0.002-0.003) were associated with increased aPR of willingness for both situations. Lower family wellbeing and communication quality were associated with lower aPR for such willingness (aPR = 0.43-0.86, P = 0.018-<0.001). Lower family wellbeing and communication quality were associated with preferences for emotion and stress management, family communication promotion, and social network building (aPR = 1.23-1.63, P = 0.017-<0.001). Conclusions: Lower levels of family wellbeing and communication quality were associated with unwillingness to attend family services and preferences for emotion and stress management, family communication promotion, and social network building.

Family context as a double-edged sword for psychological distress amid the COVID-19 pandemic with the mediating effect of individual fear and the moderating effect of household income.

Background: The COVID-19 pandemic drives psychological distress. Previous studies have mostly focused on individual determinants but overlooked family factors. The present study aimed to examine the associations of individual and family factors with psychological distress, and the mediating effect of individual fear and the moderating role of household income on the above associations. Methods: We conducted a population-based cross-sectional survey on Chinese adults in Hong Kong from February to March 2021 (N = 2,251) to measure the independent variables of anti-epidemic fatigue, anti-epidemic confidence, individual and family members' fear of COVID-19, and family well-being (range 0-10), and the dependent variable of psychological distress (through four-item Patient Health Questionnaire, range 0-4). Results: Hierarchical regression showed that anti-epidemic fatigue was positively (ß = 0.23, 95% CI [0.18, 0.28]) while anti-epidemic confidence was negatively (ß = -0.29, 95% CI [-0.36, -0.22]) associated with psychological distress. Family members' fear of COVID-19 was positively (ß = 0.11, 95% CI [0.05, 0.16]) while family well-being was negatively (ß = -0.57, 95% CI [-0.63, -0.51]) associated with psychological distress. Structural equation model showed that individual fear mediated the above associations except for family well-being. Multi-group analyses showed a non-significant direct effect of anti-epidemic confidence and a slightly stronger direct effect of family well-being on psychological distress among participants with lower incomes, compared to those with higher incomes. Conclusion: We have first reported the double-edged effect of family context on psychological distress, with the positive association between family members' fear of COVID-19 and psychological distress fully mediated by individual fear and the negative association between family well-being and psychological distress moderated by income level. Future studies are warranted to investigate how the contagion of fear develops in the family and how the inequality of family resources impacts family members' mental health amid the pandemic.

Associations of the perceived benefits and harms of COVID-19 with confidence in coping with the pandemic and mental health symptoms: a population-based survey in Hong Kong.

Introduction: Both perceived benefits and harms of COVID-19 have been reported, but whether they affect confidence in coping with the pandemic and mental health remains uncertain. Objective: To examine the association of perceived benefits and harms of COVID-19 with confidence in coping with the pandemic and mental health symptoms. Methods: A population-based survey was conducted on 7,535 Hong Kong adults from 22 February to 23 March 2021, when the 4th wave of COVID-19 was under control. Information on sociodemographic characteristics, perceived benefits (10 options) and harms (12 options) of COVID-19, confidence in coping with the pandemic (range 0-10), loneliness (range 0-4), anxiety (General Anxiety Disorders-2, range 0-6) and depression (Patient Health Questionnaire-2, range 0-6) was collected. Latent profile analysis was used to identify the combined patterns of perceived benefits and harms of COVID-19. The associations of combined patterns with confidence in coping with COVID-19, loneliness, anxiety, and depression were examined using linear regression (ß coefficient) adjusting for sociodemographic characteristics. Results: The combined patterns of perceived benefits and harms were classified into benefit (n = 4,338, 59.3%), harm (n = 995, 14.0%), and ambivalent (n = 2,202, 26.7%) groups. Compared with the ambivalent group, the benefit group had a significantly higher level of confidence (adjusted ß 0.46, 95% CI 0.33 to 0.58), and lower levels of loneliness (-0.35, -0.40 to-0.29), anxiety (-0.67, 0.76 to-0.59), and depression (-0.65, -0.73 to-0.57). The harm group had a significantly lower level of confidence (-0.35, -0.53 to-0.16), and higher levels of loneliness (0.38, 0.30 to 0.45), anxiety (0.84, 0.73 to 0.96), and depression (0.95, 0.84 to 1.07). Conclusion: Perceived greater benefit from COVID-19 was associated with better mental health and stronger confidence in coping with the pandemic.

Substantial increase in perceived benefits over harms of COVID-19 outbreak but persistent socioeconomic disparities: Comparison of two cross-sectional surveys in Hong Kong from 2020 to 2021.

Background: We have reported both perceived benefits and harms of the COVID-19 outbreak and their socioeconomic disparities amid the pandemic in Hong Kong. We further investigated whether such perceptions and disparities had changed after 10 months. Methods: Under the Hong Kong Jockey Club SMART Family-Link Project, we conducted two cross-sectional surveys online on perceived personal and family benefits and harms of the COVID-19 outbreak in Hong Kong adults in May 2020 (after Wave 2 was under control; N = 4,891) and in February and March 2021 (after Wave 4 was under control; N = 6,013). We collected sociodemographic information, including sex, age, education, household income, and housing. Using multivariate models of analysis of covariance (MANCOVA), we compared perceived benefits and harms and socioeconomic disparities between the two surveys. Results: Adjusting for sex and age, the prevalence of 17 out of 18 perceived personal and family benefits of COVID-19 outbreak increased (Ps < 0.001). Six of 11 perceived personal and family harms decreased (Ps < 0.001) and 4 increased (Ps < 0.001). The total number of perceived personal and family benefits increased substantially (Ps < 0.001), whereas that of perceived personal harms decreased (P = 0.01) and family harms remained stable (P > 0.05). Socioeconomic disparities, however, persisted-more perceived benefits in those with higher socioeconomic status (Ps < 0.001) and more perceived harms in those with lower (Ps ≤ 0.005). Conclusion: We have first reported that perceived personal and family benefits of the COVID-19 outbreak increased substantially over 10 months amid the pandemic, while perceived personal and family harms were lower and stable, respectively. Socioeconomic disparities of the perceived benefits and harms persisted, which need to be monitored and addressed urgently.

Corrigendum: Associations of Delay in Doctor Consultation With COVID-19 Related Fear, Attention to Information, and Fact-Checking.

[This corrects the article DOI: 10.3389/fpubh.2021.797814.].

A Population Study on COVID-19 Information Sharing: Sociodemographic Differences and Associations with Family Communication Quality and Well-Being in Hong Kong.

Family support through the sharing of information helps to shape and regulate the health and behaviours of family members, but little is known about how families are sharing COVID-19-related information, or about its associations with family communication quality and well-being. We examined the associations of COVID-19 information sharing methods with sociodemographic characteristics, the perceived benefits of information communication and technology (ICT) methods, and family communication quality and well-being in Hong Kong. Of 4852 respondents (53.2% female, 41.1% aged over 55 years), the most common sharing method was instant messaging (82.3%), followed by face-to-face communication (65.7%), phone (25.5%) and social media (15.8%). Female sex (adjusted prevalence ratio (aPR) 1.09), older age (aPRs 1.14-1.22) and higher household income (aPR 1.06) (all p ≤ 0.04) were associated with instant messaging use, while post-secondary education was associated with face-to-face (aPR 1.10), video call (aPR 1.79), and email (aPR 2.76) communications (all p ≤ 0.03). Each ICT sharing method used was associated with a higher likelihood of both reported benefits (aPRs 1.26 and 1.52), better family communication quality and family well-being (adjusted ßs 0.43 and 0.30) (all p ≤ 0.001). We have first shown that COVID-19 information sharing in families using both traditional methods and ICTs, and using more types of methods, was associated with perceived benefits and better family communication quality and well-being amidst the pandemic. Sociodemographic differences in COVID-19 information sharing using ICTs were observed. Digital training may help enhance social connections and promote family well-being.

Associations of Face-to-Face and Instant Messaging Family Communication and Their Contents With Family Wellbeing and Personal Happiness Amidst the COVID-19 Pandemic.

Background: Both face-to-face and instant messaging (IM) communication are important for families, but face-to-face communication has reduced amidst the COVID-19 pandemic. We examined the use and contents of both communication methods amidst the pandemic, their associations with family wellbeing and personal happiness, and the mediation effects of communication quality in Hong Kong Chinese adults. Methods: This population-based online survey enrolled 4,921 respondents in May 2020, who reported (i) any face-to-face or IM family communication when the pandemic was severe; (ii) communication contents being classified as neutral, positive, supportive, and negative; and (iii) communication quality, family wellbeing and personal happiness (score 0-10). Associations of family wellbeing and personal happiness with communication methods and contents (no communication excluded) were examined using linear regressions (ß), adjusting for each other, sex, age, socioeconomic status, and the number of cohabitants. Mediating effects of communication quality on these associations were examined. Prevalence estimates were weighted by sex, age, and education of the general population. Interactions of methods and contents were examined. Results: Of 4,891 included respondents (female: 52.9%, 45-54 years: 37.7%, ≥65 years: 21.3%), 7.1% reported no communication, 12.7% face-to-face communication only, 26.7% IM only, and 53.4% both methods. More males and those at younger ages, had lower socioeconomic status, or fewer cohabitants showed no family communication or face-to-face only. More respondents reported neutral (83.1-99.3%) than positive (42.1-62.2%), supportive (37.5-54.8%), and negative (10.9-34.5%) contents despite communication methods. Communication quality was higher with both methods than IM only, face-to-face only, and no communication (scores: 6.7 vs. 4.5-6.6, all P ≤ 0.02). Better family wellbeing and personal happiness were associated with using IM only (adjusted ßs: 0.37 and 0.48) and both methods (0.37 and 0.42) than face-to-face only, and positive (0.62 and 0.74) or supportive (0.45 and 0.46) contents (all P ≤ 0.001). Communication quality mediated 35.2-93.5% of these associations. Stronger associations between positive contents and family wellbeing showed in both methods and face-to-face only than IM only (P for interaction = 0.006). Conclusions: We have first shown that, amidst the COVID-19 pandemic, family IM communication and positive and supportive contents may promote family wellbeing and personal happiness. People with no family communication may need assistance.

Patterns of Perceived Harms and Benefits of the COVID-19 Outbreak in Hong Kong Adults: A Latent Profile Analysis.

The COVID-19 pandemic caused different types of harms and benefits, but the combined patterns of perceived harms and benefits are unclear. We aimed to identify the patterns of perceived harms and benefits of the COVID-19 outbreak and to examine their associations with socio-demographic characteristics, happiness, and changes in smoking and drinking. A population-based cross-sectional online survey was conducted in May 2020 on Hong Kong adults (N = 4520). Patterns of perceived harms and benefits of COVID-19 were identified using latent profile analysis. Their associations with socio-demographic characteristics, happiness, and changes in smoking and drinking were examined using multinomial logistic regression. We identified three distinct patterns: indifferent (66.37%), harm (13.28%), and benefit (20.35%). Compared with the indifferent subgroup, the harm subgroup was younger, less happy, and had increased drinking, and hence might be at higher risk, whereas the benefit subgroup was more likely to be female, live with one or more cohabitants, have postsecondary education, be happier, and have decreased drinking, and could be more adaptive. Future studies can target the harm subgroup to facilitate their positive adjustments.

Development and evaluation of two brief digital health promotion game booths utilizing augmented reality and motion detection to promote well-being at a gerontechnology summit in Hong Kong.

Background: The acceleration of population aging calls for simple and effective interventions catered for older people. Gerontechnology, the combination of gerontology and technology, can promote quality of life in older adults. However, public health-related events incorporating information communication technology (ICT) for older people have seldom been evaluated. Objective: We reported the development and evaluation of two simple and brief digital health promotion games hosted at the annual Hong Kong Gerontech and Innovation Expo cum Summit (GIES) in 2018 and 2019 to promote well-being. Methods: Two game booths (Dinosaur Augmented Reality photo-taking in 2018, Sit-and-Stand fitness challenge in 2019) were designed by our interdisciplinary team. Four gaming technologies were employed: augmented reality, chroma key (green screen), motion detection and 3D modeling. Immediately after the game, we administered a brief questionnaire survey to assess participant satisfaction, happiness and perceived benefits, and collected qualitative data through observations and informal interviews. Results: Majority of 1,186 and 729 game booth participants in 2018 and 2019, respectively, were female (73.4% and 64.7%) and older adults (65.5 and 65.2%). Overall satisfaction toward the game booths was high (4.64 ± 0.60 and 4.54 ± 0.68 out of 5), with females and older adults reporting higher scores. Average personal and family happiness of participants in 2018 were 8.2 and 8.0 (out of 10). 90.3 and 18.4% of participants in 2019 chose one or more personal (e.g. enhance healthy living habits 62.4%, enhance personal happiness 61.6%) and family (e.g. enhance family happiness 15.6%, improve family relationships 10.8%) benefits of the game booth, respectively. Participants showed enthusiasm toward the technologies, and pride in their physical abilities in the fitness challenge. Conclusion: Our report on the development and evaluation of brief game interventions with ICT showed high satisfaction and immediate perceived benefits in community participants. Females and older adults reported higher satisfaction. Simple tools measuring happiness and perceived benefits showed positive results. Older adults were receptive and enthusiastic about the new technologies. Our findings can inform researchers and organizers of similar events. More research on simple and enjoyable ICT interventions is needed to attract older adults and promote their well-being. Trial registration: The research protocol was registered at the National Institutes of Health (Identifier number: NCT03960372) on May 23, 2019.

Association of family wellbeing with forwarding and verifying COVID-19-related information, and mediation of family communication quality.

Objective: We assessed the associations of family wellbeing with verifying and subsequently forwarding COVID-19-related information to family members and the mediating effect of the quality of family communication on these associations among Chinese adults in Hong Kong. Methods: Under the Jockey Club SMART Family-Link Project, we conducted an online population-based survey, using Family wellbeing Scale and questions related to the family communication quality and forwarding and verifying COVID-19 information. Data were collected from 4,891 adults in May 2020. Prevalence estimates of forwarding and verifying COVID-19 information were weighted by sex, age, and education of the general population, and their associations with family wellbeing (ranged 0-10) were analyzed using generalized linear models with mutual adjustment. Their interactive effects on family wellbeing and the mediating effects of family communication quality were examined. Results: In total, 53.9% of respondents usually/always forwarded COVID-19 information related to their family, 68.7% usually/always verified it before forwarding, and 40.9% did both. Greater family wellbeing was associated with usually/always forwarding [adjusted ß (95% CI): 0.82 (0.72-0.92)] and usually/always verifying [0.43 (0.32-0.55)] (both P < 0.001) the information. Forwarding and verifying such information showed an additive effect on family wellbeing [1.25 (1.11-1.40)]. Family communication quality mediated the associations of family wellbeing with forwarding (83.7%) and verifying (86.6%) COVID-19-related information. Conclusion: Forwarding COVID-19 information to family, verifying such information, and especially doing both, were associated with greater family wellbeing, being strongly mediated by the quality of family communication. Individuals should be encouraged to verify COVID-19-related information before forwarding it to family members amidst the COVID-19 pandemic.

An Exploratory Trial of Brief Mindfulness-Based Zentangle Art Workshops in Family Social Services during COVID-19: Transitioning from Offline to Online.

Mindfulness-based art therapy has shown to improve psychological well-being. Zentangle is an easy-to-learn, mindfulness-based art therapy suitable for everyone. We reported the transition from face-to-face to online Zentangle workshops in family social services during COVID-19. We explored feedback from face-to-face workshops and the acceptability of an online approach utilizing information communication technology (ICT) to achieve greater service reach, satisfaction, and knowledge and related outcomes. Under the Hong Kong Jockey Club SMART Family-Link Project and in collaboration with Caritas Integrated Family Service Centre-Aberdeen, this study was conducted in two phases: a four-session, face-to-face workshop (phase one) and eleven online single-session workshops (phase two) from September 2019 to September 2020. A total of 305 participants joined the workshops. Phase one participants (n = 11) reported high satisfaction (4.7 out of 5), increases in knowledge (4.2/5) and confidence (3.9/5) towards managing stress, increases in knowledge (4.1/5) and confidence (3.9/5) in showing support and care towards family members, and an increase in knowledge towards strengthening family relationships (4.0/5). Phase two participants (n = 294) also reported high satisfaction (4.7/5) and strongly agreed that ICT helped with learning Zentangle more conveniently, that they had increased knowledge and interest in Zentangle (all 4.7/5), and would definitely join the workshop again (4.8/5). The qualitative data supported the quantitative findings. We are the first to report on the utilization of ICT in an exploratory trial of brief, online Zentangle art workshops targeting the general public, with high satisfaction and positive participant experiences with ICT integration, learning Zentangle, and enhanced psychological and family well-being. This study provided preliminary evidence on the use of ICT to successfully transition face-to-face to online workshops and reach a wider audience.

Fear of COVID-19 and its associations with perceived personal and family benefits and harms in Hong Kong.

Fear of COVID-19 is associated with public health compliance but also with negative well-being; however, no articles have reported associations of such fear with perceived benefits and harms. We assessed the level of fear of COVID-19 in Hong Kong adults and its associations with sociodemographic factors and perceived benefits and harms of COVID-19. In a 6-day population-based cross-sectional online survey in May 2020, 4,890 adults provided data on fear and perceived benefits and harms, personal happiness and family well-being, and sociodemographic characteristics. Linear regression was used to analyze associations. The level of fear was moderate (mean score 6.3/10). Fewer respondents reported perceived benefits (10.6%-21.7%) than harms (13.4%-43.5%). Females, younger age groups, and respondents with lower education or more cohabitants had greater fear. Fear was associated with perceived personal (increased knowledge of personal epidemic prevention) and family benefits (improved family hygiene), both with a very small effect size (Cohen's d = 0.03). Fear was also associated with lower personal happiness and perceived personal (increased negative emotions, feeling depressed and anxious, decreased income, and decreased work efficiency) and family harms (increased conflicts and negative emotions among family members), with small effect sizes (0.08-0.37). We have first shown sociodemographic differences in the fear of COVID-19 and such fear was associated with both perceived personal and family benefits and harms of COVID-19. Our findings may guide the management of fear to reduce sociodemographic differences, and maximize benefits and minimize harms.

Facemask Wearing Among Chinese International Students From Hong Kong Studying in United Kingdom Universities During COVID-19: A Mixed Method Study.

Background: The mental health of international students studying abroad has been neglected during the COVID-19 pandemic. Objective: This mixed-method study examined perceived public attitudes, personal beliefs, practice and stress toward facemask wearing as a preventive measure against COVID-19 among international University students from Hong Kong studying in the United Kingdom (UK) in the early stage (January-March 2020) of the pandemic. Methods: Our study included 2 parts: (i) an exponential, non-discriminative snowball sampling strategy was used to recruit 91 Chinese students studying in the UK to complete an online questionnaire survey, and (ii) online Zoom focus group interviews were conducted with 16 students who completed the online survey to gain an in-depth understanding of their experiences and coping methods during the pandemic. Results: Of the 91 students, 92.3% reported the UK public did not view facemask wearing as a preventive measure. 98.9% believed facemask wearing was an effective preventive measure, but 56% wore facemasks more than half of the time when out in public. 50.5% had internal conflicts of stress both when wearing and not wearing facemasks, which was more common in females than males [(62.5 vs. 31.5%), P = 0.004, Relative Risk (RR): 1.99 (1.17, 3.38)]. 61.5% reported public prejudiced attitudes against facemask wearing, also more common in females than males (71.4 vs. 45.7%), P = 0.02, RR: 1.56 (1.05, 2.32). The qualitative findings corroborated with the quantitative findings and reported that peer and family support were important for them to face such difficulties, and positive thinking and adaptability were effective methods on stress management. Conclusions: Since the outbreak of COVID-19, Chinese international students have been faced with a difficult, confusing, and sensitive situation. Owing to the ongoing pandemic, rising xenophobia and racist behaviors and the resumption of students' studies studies in the U.K., support from global communities are needed in their pursuit of quality education overseas. Our findings have significant implications on the proactive roles that governments should have, and the need for clear and accurate public health messaging to change public attitudes and mitigate prejudice. Academic institutions and mental health professionals need to proactively provide additional support to Chinese international students.

A Phenomenological Study on the Positive and Negative Experiences of Chinese International University Students From Hong Kong Studying in the U.K. and U.S. in the Early Stage of the COVID-19 Pandemic.

Background: The COVID-19 pandemic has caused distress in students globally. The mental health of international students studying abroad has been neglected during the COVID-19 pandemic, especially Chinese students who have been unfairly targeted. Objective: To explore and document the positive and negative experiences of a group of Hong Kong Chinese international students studying in the U.K. and U.S. from an insider perspective in the early stage of the COVID-19 pandemic. Methods: The qualitative study used four 1.5-h online focus group interviews of 20 Chinese international students from Hong Kong aged 18 or older studying in universities in the United Kingdom or the United States, from 3 May to 12 May 2020. A framework approach with a semi-structured interview guide was used to reflect students' stressors, cognitive appraisals, coping, and outcomes (negative impacts and positive gains), in the early stages of COVID-19. Different strategies were used to ensure the credibility, dependability, confirmability, and transferability of the study. Transcripts were analyzed using qualitative thematic content analysis. Results: Twenty full-time international University students (60% female, 90% aged 18-25 years and 65% undergraduates) were recruited. Students reported (i) stress from personal (e.g., worries about health and academic attainment), interpersonal (e.g., perceived prejudice and lack of social support), and environmental factors (e.g., uncertainties about academic programme and unclear COVID-19-related information); (ii) significant differences in culture and cognitive appraisal in the levels of perceived susceptibility and severity; (iii) positive thinking and using alternative measures in meeting challenges, which included effective emotion and problem coping strategies, and the importance of support from family, friends and schools; and (iv) negative psychological impact (e.g., worries and stress) and positive personal growth in crisis management and gains in family relationships. Conclusions: With the rise in sinophobia and uncertain developments of the pandemic, proactive support from government and academic institutions are urgently needed to reduce stress and promote the well-being of international students, especially Chinese students in the U.K. and U.S. Clear information, public education and policies related to the pandemic, appropriate academic arrangements from universities and strong support systems play important roles in maintaining students' psychological health. Clinical Trial Registration: The study was registered with the National Institutes of Health (https://clinicaltrials.gov/, identifier: NCT04365361).

Associations of Delay in Doctor Consultation With COVID-19 Related Fear, Attention to Information, and Fact-Checking.

Background: Delaying doctor consultation is harmful. Fear of COVID-19 leads to delays in seeking medical care at a time when pandemic information overflows. However, little is known about the role of COVID-19 related fear, attention to information, and fact-checking in such delay. Objective: Under the Hong Kong Jockey Club SMART Family-Link Project, we examined the associations of delay in doctor consultation amidst the pandemic with sociodemographic characteristics, COVID-19 related fear, attention to information, and fact-checking. Methods: We conducted a population-based online cross-sectional survey in May 2020 on Hong Kong Chinese adults. Respondents reported whether the pandemic caused any delay in doctor consultation (yes/no), level of COVID-19 related fear, attention to information and fact-checking (all on a scale of 0 to 10 and recoded into tertiles of low, moderate, high). Regression analyses were used to examine the associations of delay and fear with sociodemographic characteristics, attention and fact-checking, adjusting for covariates. Data were weighted by sex, age and education level of the population. Results: Of 4,551 respondents (46.5% male, 59.7% aged over 45 years), 10.1% reported delay in doctor consultation. The mean score was 6.4 for fear, 8.0 for attention and 7.4 for fact-checking. Delay was more common in males and increased with age and fear. High vs. low level of fear was associated with delay [adjusted odd ratios (AOR) 2.68, 95% confidence interval (CI) 2.08, 3.47]. Moderate level of fact-checking was negatively associated with delay (AOR 1.28, 95% CI 0.98, 1.67). Females reported greater fear and fear decreased with age. Fear increased with attention to information and decreased with fact-checking. Fear substantially mediated the association of delay with attention (96%) and fact-checking (30%). Conclusions: We have first shown that delay in doctor consultation increased with fear of COVID-19 and decreased with fact-checking amidst the pandemic. Fear also increased with attention to COVID-19 related information and decreased with fact-checking. Understanding these associations can help policymakers develop targeted communication and support to the public to reduce delayed doctor consultations and the associated COVID-19-related or unrelated morbidity and mortality in the community.